Chapter three: health and nutrition interventions for women.

Because the factors that affect women's well-being and productivity cover a wide spectrum, policymakers and program planners have to make difficult decisions about priorities. To provide a rational basis for making such choices, this chapter begins by describing a minimum package of women's health interventions that should be priorities for most developing countries. It then presents a set of expanded interventions that can be instituted as resources permit The interventions included in both packages were selected for their impact in reducing female disability and death, their affordable cost, and their feasibility in developing countries (see the Appendix). Although estimates of cost-effectiveness are not widely available for education and communication efforts, such measures are described because of their strong potential for influencing health-related attitudes and practices.

The essential services for women's health confer widespread economic and social benefits of sufficient importance to justify public funding. Many of these interventions relate to women's reproductive and sexual health.

The expanded services comprise interventions that can be implemented I ' middle-income countries (and by poorer countries to the extent that funds permit) to reap even more gains. They are primarily enhancements of the essential services, interventions for women beyond reproductive age, and interventions to promote behavioral change in order to prevent health and nutrition problems and reduce gender discrimination and violence.

Although the two sets of recommended interventions are beneficial to all women, specific strategies will need to be tailored to the particular economic, epidemiological, demographic, and infrastructural conditions of each country or local setting. The cultural and socioeconomic factors that affect women's lives must also be taken into account when prioritizing interventions and planning delivery strategies. Potentially cost-effective devices for disease prevention, such as condoms, sometimes fail in practice because social mores prevent women from negotiating their use.

Essential Health Interventions

Essential health interventions fall into three categories: prevention and management of unwanted pregnancies, pregnancy services, and prevention and management of STDs (Table 3.1).

Prevention and Management of Unwanted Pregnancies

Preventing unwanted pregnancies improves women's health by reducing their exposure to the complications of pregnancy, childbirth, and unsafe abortion. In addition, the survival chances of children are significantly influenced by the timing and spacing of births, as well as by overall family size. Health services can best address the problem of unwanted pregnancy by providing family planning services and--where national policies permit--safe services for termination of pregnancy.

Family planning services. Where fertility and mortality rates are high, family planning alone can have a substantial impact on maternal mortality. For example, in a rural subdistrict of Bangladesh, the maternal mortality rate fell by about one-third following an effective community-based project that raised contraceptive prevalence to more than 50 percent, compared with 23 percent in the control area (Fauveau 1991). Providing family planning services costs, on average, only $15 to $150 per DALY saved in low-income countries (about $20 per contraceptive user) and is one of the most cost-effective health interventions. In countries where both mortality and fertility are still relatively high, the cost per child death prevented is also extremely low. In Mali, for example, it averages about $ 130, or $4 to $5 per DALY gained (World Bank 1993b).

Programs should provide high-quality, consumer-oriented family planning services that promote informed reproductive choice. Because contraceptive needs and preferences change throughout a woman's life, a good selection of short- and long-term methods should be provided. Health agencies should establish a variety of service-delivery points and encourage commercial outlets to offer contraceptives for sale at reasonable cost. Condoms, oral contraceptives, and spermicides can be made available immediately, even in resource-poor settings, since they can be provided by community-based distributors with appropriate training and sold through commercial outlets. Trained paramedical workers (nurses and midwives) can safely provide most other methods, including injectables, implants, intrauterine devices (IUDS), and voluntary sterilization.

Breastfeeding also plays an important role in child spacing and can complement other family planning methods. During the first six months after giving birth, a woman who is amenorrheic (having no menses) and feeding her baby only breastmilk receives 98 percent protection against pregnancy (Georgetown University School of Medicine 1990). Infants also derive health benefits from exclusive breastfeeding for the first six months and from breastmilk supplemented with other food for up to a year and a half thereafter. Health workers at all levels should encourage mothers to breastfeed and consume an adequate diet to meet the added nutritional needs that breastfeeding demands.

Making contraceptives widely available can greatly reduce the incidence of unsafe abortion. In Santiago, Chile, for example, deaths and hospitalization for complications from abortion fell dramatically after free IUD insertions were offered in 1964. As contraceptives became increasingly available throughout Chile, abortion-related deaths and complication rates plummeted (Figure 3.1). Safer abortion, although still illegal, may also have played a role.

Management of complications from unsafe abortion and safe services for terminating pregnancy. Women's health care can be greatly improved by timely and appropriate treatment of abortion complications, as well as providing postcoital contraception and safe termination of pregnancy. Complications from unsafe abortion (hemorrhage, shock, and sepsis) are often life-threatening and costly to treat, requiring emergency referral, two to three days of hospital care, anesthesia, antibiotics, surgery, and blood transfusion. Vacuum aspiration abortion, provided by a trained health worker early in pregnancy, is up to a thousand times safer than clandestine abortion (Johnson, Benson, and Hawkins 1992). Safe abortion is one of the most cost-effective measures for reducing maternal death and disability.

Abortion during the first trimester and treatment of incomplete abortion without complications can be handled safely at primary-level health centers on an outpatient basis by trained nurses, midwives, or paramedics using vacuum aspiration (McLaurin, Hord, and Wolfe 1991; Rosenfield 1989). Dilation and curettage requires more surgical skill and anesthetic support Health facilities that provide abortions or treat complications arising from unsafe abortions can realize substantial savings by using vacuum aspiration. In one year a single Kenyan hospital saved an estimated $300,000--equal to the annual salaries for 200 nurses--by switching from dilation and curettage to vacuum aspiration to treat incomplete abortions (Kizza and Rogo 1990). Reducing the incidence of incomplete abortions would lower hospital costs even more. Following an abortion, women should receive counseling, services, and referrals as needed to ensure they have the means to prevent unwanted pregnancy in the future.

[FIGURE 3.1 OMITTED]

Where abortion is legal but not widely available (as in India), programs should strive to increase access by expanding services, delegating responsibility, and training mid-level providers. In areas where abortion is routinely used for birth control (as in parts of Eastern Europe and Central Asia), programs need to increase the availability of contraceptives and to provide postabortion family planning information and services.

Pregnancy Services

Safe pregnancy services are designed to ensure timely detection, management, and referral of complications during pregnancy, labor, and delivery. About one in three pregnant women develop complications requiring treatment from a trained provider, and one in ten require hospitalization. (A more detailed discussion of pregnancy-related services can be found in Tinker and Koblinsky 1993.)

Because of their impact on the health of the child as well as the mother, safe pregnancy services are highly cost-effective. Providing prenatal, delivery, and postpartum services costs less than $2,000 per death averted, or between $30 and $250 per DALY saved (World Bank 1993b). In resource-poor countries, priority should be given to improving hygienic practices, providing iron and folate supplementation, and strengthening linkages and referral services for obstetric complications.

Prenatal care. Regular prenatal care is needed to help detect and manage some pregnancy-related complications (such as pre-eclampsia, infection, and obstructed labor) and to educate women about danger signs, potential complications, and where to seek help. In Ethiopia and Nigeria, nurse-midwives working with traditional birth attendants referred short women having their first birth to the hospital for delivery. This program substantially reduced the number of maternal deaths from obstructed labor. Prenatal care also provides an opportunity to offer preventive care that will benefit the infant as well as the mother (such as counseling on hygiene, breastfeeding, nutrition, family planning, tetanus toxoid immunization, and iron and folate supplementation) and to treat existing diseases that may be aggravated by pregnancy (such as malaria). Unfortunately, there is no established protocol for either the content or the timing of prenatal care. This is an issue of concern for any maternal health program and deserves immediate attention.

Because most pregnancy-related complications cannot be anticipated, all women need access to appropriate care should complications develop. In Ethiopia, for example, maternity waiting homes have been established near hospitals to bring women living in remote areas to obstetric care before the expected due date (Brennan 1992; Poovan, Kifle, and Kwast 1990).

Because newborns and mothers can contract tetanus from nonsterile delivery procedures, immunization against tetanus is especially important for women who deliver in nonmedical settings. Immunizing pregnant women against tetanus costs less than $6 per DALY saved, based on infant deaths averted (Jamison 1993).

The regular intake of iron and folate tablets can prevent or cure anemia among pregnant and lactating women. Providing iron supplementation for pregnant women is highly cost-effective, at a cost of less than $2 to $4 per person annually, or less than $13 per DALY saved, based on infant deaths averted (World Bank 1993b). Iron pills should be routinely provided to pregnant women and properly stored to protect quality. Pills can also be made available through community-based distribution and commercial outlets. Training for health care providers and consumer education can improve patient compliance. Fortification of commonly used foods (salt or sugar) with iron, iodine, and vitamin A is even more cost-effective than supplementation.

Where iodine deficiency is endemic, providing iodized oil to women of reproductive age is a low-cost addition to existing maternal and child health services, particularly where iodized salt is not available. The most effective long-term approach to reducing iodine deficiency is iodization of salt for the whole community. Use of injected or oral iodized oil every two to five years among women of reproductive age costs less than $19 per DALY saved, based on child deaths averted (World Bank 1993b).

At about the fourteenth week of gestation, especially in a first pregnancy, women's resistance to malaria begins to diminish. While providing bed nets and antimalarial drugs to pregnant women in infested areas can prevent severe illness and reduce the associated risk of low-birthweight infants (Steketee 1989), prompt diagnosis and proper treatment of malaria during pregnancy may be the most cost-effective course of action.

Safe delivery. Delivery care should include safe management of routine deliveries, safe-birth kits for traditional birth attendants, communication and transport to ensure timely referral and management of emergency complications, and essential obstetric functions at the first-referral level.

Health agencies should be able to ensure hygienic routine delivery in the community by trained paramedics, particularly midwives, or traditional birth attendants. Most postpartum hemorrhage, which is largely unpredictable, can be prevented if skilled birth attendants effectively manage the third stage of labor. Sepsis at delivery can be largely prevented by minimizing vaginal examinations and ensuring clean delivery practices. When rupture of the membranes occurs long before labor, antibiotics should be provided.

Most life-threatening complications occur during labor and delivery, and because most of these cannot be predicted, every woman needs access to emergency obstetric care. Effective treatment of hemorrhage often includes rapid manual removal of retained placenta, oxytocic drugs, intravenous fluids, blood transfusion, and surgery. In cases of hemorrhage, obstructed labor, and other obstetrical emergencies, the most important element in a woman's treatment may be transportation. Death from hemorrhage, for example, usually occurs within two hours of onset When distance is a factor, first aid at the community or health center level may be necessary to save a woman's life by stabilizing her condition until she reaches the hospital. Advance planning for emergencies is therefore key to reducing maternal mortality.

Specially trained staff are needed to perform some obstetrical procedures (cesarean section and symphysiotomy for obstructed labor, laparotomy or hysterectomy to stop persistent bleeding, treatment for eclampsia and sepsis, and repair of obstetric fistulae). In Zaire, women's lives have been saved by nurses trained to perform cesarean sections (White, Thorpe, and Maine 1987).

Efforts must also be made to improve existing services. Major barriers to utilization include long distances to health facilities, inadequate transportation, lack of funds to pay for transport and health care, lack of knowledge about the benefits of formal health care, and low-quality care.

Postpartum care. Postpartum care should include early detection and management of infection and hemorrhage, support for exclusive breastfeeding for six months, nutrition counseling, and family planning services. Even among women who have delivered in a hospital, postpartum follow-up is important because complications may arise after leaving inpatient care. Educating women, their families, birth attendants, and community health workers to recognize early signs of and seek care for infection, for example, may be lifesaving. Antibiotic treatment is sufficient to cure infection in more than 80 percent of cases if taken within four days of the onset of fever (Winikoff and others 1991).

Postpartum care should respond to women's needs and preferences to ensure utilization and effectiveness. In Tunisia the innovative Sfax program delivers integrated family planning and health services to the mother and child by linking postpartum care with a cultural tradition. In addition to follow-up and counseling immediately after birth, the program provides health services and information for the mother and the infant on the fortieth day after birth, a day of religious and cultural importance for Tunisian mothers and children (Coeytaux 1989).

Prevention and Management of STDs

At the primary health care level, efforts to control STDs should focus on preventing transmission and treating infection in order to avert severe complications. Since the emergence of HIV/AIDS as a major public health problem and the identification of STDs as risk factors for its spread, primary prevention of STDs merits increasing attention.

Treating STDs costs only $1 to $55 per DALY saved (World Bank 1993b). Preventing a single STD case in a woman is estimated to be almost 20 percent more effective than preventing a single case in a man (Over and Piot 1993). Women are more susceptible to catching STDs from men than vice versa, and the severity of STDs (other than HIV) is generally greater in women than in men. In addition, preventing and curing STDs in women who are or may become pregnant reduces perinatal transmission.

The costs of treating STDs are much lower than the costs of treating their complications or the enormous direct and indirect costs of widespread STD and HIV infection (Piot and Rowley 1992). Although the lack of simple, inexpensive diagnostic tests for most STDs constrains control programs in areas with limited resources and facilities, syndromic diagnosis of STDs--based on characteristic groups of symptoms--can often be used in men and may be useful in symptomatic women.

Factors such as the emergence of antimicrobial resistance, the prevalence rate of STDs in the population, and the feasibility of reaching at-risk groups (including partner notification) must be considered when weighing program options. Health care providers should concentrate on making services available to high-frequency transmitters, particularly commercial sex workers, who contribute substantially to the spread of infection. The cost-effectiveness of interventions drops rapidly when they are directed at the general population. Where the infection has spread beyond high-risk groups, however, a broader approach is warranted.

Because contracepting and pregnant women are sexually active and therefore at risk, it is desirable and cost-effective to offer STD counseling, diagnosis, and treatment at clinics that also provide maternal and child health care and family planning. In addition, clustering of services is more cost-effective. Single-purpose STD programs often fail to reach women too embarrassed to use them and those who are asymptomatic or who fail to recognize symptoms.

Health workers at all levels--including traditional birth attendants--should be trained to recognize STD symptoms and to use appropriate treatment and referral protocols. Health workers should also be trained to counsel on condom use, identify sexual contacts, and assist in notification of partners when necessary.

Drugs for treating STDs should be included on national lists of essential drugs. Distribution should be encouraged through commercial channels and subsidized as necessary. Under a social marketing project in Cameroon, pharmacies sell an std treatment kit containing antibiotics, instructions, a "partner referral" card to encourage partners to purchase the kit, std information, and condoms (FHI 1992).

Condom promotion and distribution. Aside from abstinence or changes in sexual behavior, condoms are the most effective means of preventing sexual transmission of STDs, including HIV/AIDS. To promote condom use, governments need to lower import duties and other fees (which typically raise condom prices by 35 to 100 percent) and permit condom advertising. Subsidizing condom distribution and promotion is estimated to cost $76 per DALY gained, taking into account how adults and children may be affected by STDs, aids, and cervical cancer (a secondary effect of some STDs). Factoring in family planning benefits reduces the cost per DALY gained (based on child outcomes) to $45, making condom distribution even more cost-effective (Jamison 1993).

To date, subsidized commercial sales, community-based distribution, and workplace programs have been effective means of distributing condoms to both high-risk groups and the general population. A community-wide intervention in Zimbabwe distributed more than 5.7 million condoms and reduced the incidence of STDs by 6 to 50 percent in different areas (World Bank 1993b). In Zaire a 1987 mass media and condom marketing program was highly effective: more than 80 percent of women surveyed had heard about AIDS on the radio, and condom sales rose to seven times previous levels in one year (Liskin and others 1989).

Prenatal screening and treatment for syphilis. Cost-effectiveness estimates for treatment of syphilis vary greatly, depending upon its prevalence, assumptions about the risk of transmission, and the case-detection strategy used. In most developing countries, screening for syphilis using the Rapid Plasma Reagin test, which provides immediate results, followed by treatment with penicillin (where indicated), is a simple and inexpensive approach with significant payoffs for infant health (Schulz, Schulte, and Berman 1992). Accordingly, screening and treatment of syphilis during prenatal care is recommended. A project in Zambia reduced the incidence of syphilis among pregnant women by 60 percent within one year at a cost of $0.60 per prenatal screening and $12 per maternal syphilis case averted (Hira and others 1990).

The most serious consequence of gonorrhea and chlamydia in pregnant women is the occurrence of ophthalmia neonatorum, a severe eye infection that can cause blindness in newborns. Routine antibiotic prophylaxis for this condition In the newborn, which costs only $1.40 per case averted, is recommended rather than screening and treatment of all pregnant women (Schulz, Schulte, and Berman 1992).

Symptomatic case management. Syndrome-based treatment of both urethral discharge (most commonly caused by gonorrhea and chlamydia) and genital ulcer diseases in symptomatic men is recommended. Symptomatic women with genital ulcers or pelvic inflammatory disease should also be diagnosed and treated using clinical algorithms developed by who. By following the step-by-step guidelines developed by who, health workers can match patient symptoms with those for locally prevalent STDs and provide treatment accordingly. Clinical and laboratory diagnosis of STDs is generally not feasible in low-resource countries, particularly in rural areas, because of cost and the unavailability of trained technical personnel and laboratory equipment (Lande 1993; Piot and Rowley 1992).

Targeted screening and treatment of commercial sex workers. When targeted to frequent transmitters of infection, screening and treatment can be extremely cost-effective. A project to diagnose and treat STDs among prostitutes in Nairobi, for example, reduced the mean annual incidence of gonorrhea in this group from 2.85 cases per woman in 1986 to 0.66 cases per woman in 1989. The project also prevented an estimated 6,000 to 10,000 new cases of HIV infection, at approximately $8 to $12 per case, in addition to preventing other STDs (Moses and others 1991).

International efforts are now under way to develop rapid, accurate diagnostic methods for resource-poor settings and to introduce them into STD programs through the STD Diagnostics Initiative. Formed in 1990 by a group of STD experts from around the world, the initiative is developing quick, inexpensive tests for chlamydia, gonorrhea, and syphilis.

Essential Interventions for Behavioral Change

In addition to adopting the health care measures outlined above, countries can also benefit substantially from strategies to inform the public and change health-related behavior. Supportive health policies, including laws, government regulations, and health care protocols, are also essential.

Promoting Positive Health Practices

Information, education, and communication programs can change the attitudes and practices of men and women, health care providers, opinion leaders, and policymakers. Through broad education programs using mass media, community meetings, outreach workers, and other communication channels, health agencies can promote clinic attendance, educate consumers on healthy lifestyles and treatment alternatives, allay fears, refute false rumors, help shape social norms, and build a constituency for women's health and nutrition programs. Entertainment media have proven effective in promoting a variety of health-related behaviors, including family planning, aids prevention, better nutrition, and smoking cessation. Educational programs in clinic waiting areas reduce the time that doctors need to spend informing patients about health matters.

Public education programs and counseling teach women how to recognize the signs of disease and when and where to seek help. They can also enable women to treat minor ailments at home, while urging them to seek timely intervention at the first sign of serious problems. The promotion of specific household behaviors (such as washing hands and boiling water) can have a noticeable impact on the entire family's health. Teaching women and family members to recognize danger signs during pregnancy and to seek prompt medical attention can greatly reduce the incidence of maternal deaths. In Zaria, Nigeria, a radio campaign stressing the dangers of a labor lasting more than twenty-four hours is credited with a significant decrease in the incidence of obstetric fistulae (Harrison and others 1985).

Delayed childbearing among adolescents. Laws and regulations have a major impact on the availability and accessibility of contraceptives and abortion. Where early marriage contributes to early childbearing, governments can raise the legal age of marriage and provide incentives for young women to postpone marriage and remain in school. Health workers can publicize the harmful effects of early childbearing and closely spaced pregnancies. Satisfied users of contraception can serve as peer motivators to reinforce these messages. Proscriptions regarding contraceptives and medical procedures and spousal consent requirements can be relaxed. Health agencies can have far more impact if they can ensure adolescents and unmarried women access to confidential reproductive and sexual health information and services, protected by law.

Programs need to target adolescents as a discrete group (Box 3.1). Messages, media use, outreach programs, and service outlets need to focus on adolescents' preferences and appeal to them directly. Whenever possible, adolescents should be involved in program planning. In general, education programs that are implemented by peers have been more effective than adult-directed initiatives. Multiservice centers that integrate recreation and education with health services are effective in recruiting adolescents but may be costlier per contraceptive user than family planning clinics or outreach activities (Senderowitz forthcoming).

BOX 3.1 REACHING ADOLESCENTS

When the Gente Joven ("Young
People") program of the Mexican Family
Planning Foundation was established
in 1986, Mexican schools did
not provide sex education. Gente
Joven filled the gap by bringing information
on sexuality and family planning
to young people in poor urban
areas. Its goals are to:

* Help teenagers make their own decisions,
rather than simply provide
them with contraceptives. Gente
Joven focuses on the emotional and
social issues as well as the biological
and clinical aspects of sexuality.

* Recognize gender differences that
Influence sexual activity and contraceptive
use. For example, a study on
aids prevention revealed that girls are
reluctant to bring up the subject of
condom use because it might be interpreted
by boys as evidence of too
much sexual experience. Gente
Joven incorporates such information
into its program strategies.

* Focus on how ideas are communicated,
as well as on what the message
conveys. Video and radio are
widely used by Gente Joven because
they are particularly effective channels
for communicating with teenagers.

Source: Marques 1993.

Schools should provide instruction in reproductive physiology and sex education--not only information on when conception occurs and how to prevent it, but also negotiating skills--as part of family life education or as an integral part of the school curriculum, starting before sexual activity has begun. Studies have shown that access to counseling and contraceptives does not encourage earlier or increased sexual activity (Grunseit and Kippax 1993).

Mass media campaigns can be effective in reaching adolescents. In Jamaica the National Family Planning Board broadcast television and radio spots and songs with the message, "Before you be a mother, you got to be a woman" (Church and Geller 1989). Yet while campaigns promoting delayed childbearing seem to be well received, there has been little analysis of their specific effects on behavior.

Safe sex. Safe sex has been defined as sex that is safe from unwanted pregnancy, disease, and the unwanted use of power in sexual relationships (IPPF 1993). Because most people know little about STDs and HIV/AIDS transmission, symptoms, and long-term risks, public education programs need to explain why people should adopt preventive behaviors (including abstinence, monogamy, nonpenetrative sex, condom use, and other behaviors that reduce exposure) and why they should seek treatment. Despite some controversy, mass media campaigns have been effective in informing the public about STDs and AIDS and in changing sexual behavior. Following a nine-month mass media campaign in Mexico, for example, condom use rose among university students, prostitutes, and other audiences (Liskin and others 1989).

In general, women know less about STDs and aids than do men, learn about them later, and ore less likely to hear about them from the mass media (Liskin and others 1989). Personal contacts with individual women or groups of women may be needed. Women can be approached at places where they usually meet, such as clinics, schools, market squares, and farms, or through grassroots organizations such as market women's associations and church groups (Post 1993). Education programs should reach women of all ages, including women of childbearing age, young girls who are not yet sexually active, and older women, who often educate and advise youth.

Counseling women in negotiating skills can help them persuade their partners to use condoms, and condom promotion campaigns can change men's negative image of condoms. Over the long term, fundamental attitudinal and behavioral change is needed to make gender relations more equitable, to ensure that women have more power to protect themselves against unwanted pregnancy and disease and that men share responsibility for the sexual health of their partners. Intensified research to develop effective female-controlled methods of STD prevention (such as a vaginal microbicide) is urgently needed.

Adequate nutrition. Health agencies can help inform people about women's nutritional needs at different stages of the life cycle and can promote better diets for girls and women. In addition, government agencies can identify the need for programs that address contributory problems, such as poverty, women's heavy workload, high fertility, lack of safe water supplies, and poor sanitation. Health workers can be trained to recognize nutritional deficiencies and to counsel patients on corrective measures. To be effective in countering harmful food taboos and changing food allocation patterns within households, messages must be tailored to local conditions.

High priority should be given to improving nutritional intake among young and adolescent girls in order to prevent health problems in later life. In areas where .girls receive less or poorer-quality food than boys, health workers need to make an extra effort to educate caregivers on the long-term consequences of this practice. Special initiatives such as home visits, school meals, and other supplemental feeding programs may be helpful in improving girls' nutrition.

Even with little increase in household spending on food, nutrition education programs can influence food selection, preparation techniques, adherence to food prescriptions, use of vitamins and other supplements, and the treatment of diarrhea and other diseases that inhibit food absorption. Nutrition education programs have been successful in a variety of settings in promoting breastfeeding and appropriate weaning foods. They can also be used to promote low-cost, nutritious foods that are readily available and to encourage the cultivation of micronutrient-rich crops in home gardens as a way of ensuring an adequate supply of suitable foods. A project in West Sumatra, Indonesia, for example, promoted dark-green leafy vegetables (which are rich in iron and vitamin A) through the radio and other media. After the 1987-89 campaign, the proportion of pregnant women who consumed these vegetables daily rose from 19 to 32 percent (Favin and Griffiths 1991).

Increased male involvement and support In many cultures men make the decisions about such health-related concerns as food purchases and distribution within the family, family size, birth spacing, and the use of health care. In Senegal, for example, a study seeking to learn why so few women used maternal health services found that only 2 percent of the women interviewed said they would decide for themselves to seek care in the event of pregnancy-related complications. For most, the decision rested with their husbands (Thaddeus and Maine 1990). Education programs a; id services directed to men are needed to promote contraceptive use, safe sex, and reduction of substance abuse and violent behavior.

Health and other agencies need to make a concerted effort to make men aware of women's health problems and encourage them to take responsibility for the effects of their behavior. Reaching boys, both in and out of school, with reproductive health education is important because men so often dominate the sexual relationship. School-based and mass media programs that reach boys at a young age can be particularly effective in shaping later attitudes and practices.

To date, few health and nutrition education programs have been targeted to men. Examples of male-oriented programs are found in Honduras, Kenya, and Thailand, where breastfeeding campaigns urge the man to help his lactating wife by providing her with extra food and liquids and assuming extra chores to enable her to rest (Green 1989). In Mali a multimedia campaign was mounted to persuade men to provide women with additional and more nutritious foods during pregnancy (Fishman, Toure, and Gotten 1991).

To increase men's role in preventing unwanted pregnancy, family planning programs need to reach out to men to promote the use of male methods of contraception, support for their partner's contraceptive use, and increased spousal communication about family size, fertility regulation, and disease prevention. One approach is to establish hours or clinics for men only. PROFAMILIA, a Colombian family planning association, has created men's clinics annexed to a longstanding program directed primarily to women. The clinics provide family planning and diagnosis and treatment of urological and sexual problems, infertility, and STDs (Rogow 1990).

The imbalance in contraceptive responsibility is particularly evident for voluntary sterilization. Despite the advantages of vasectomy over female sterilization--lower health risks, lower cost, and shorter recuperation time--female sterilization procedures predominate in nearly all countries. In Latin America, women obtain 93 percent of all sterilizations (PAHO 1993). Even in Thailand, where vasectomy has been heavily promoted, women obtain four in five sterilizations (Ross, Mauldin, and Miller 1993). The "no-scalpel" technique of vasectomy, which has further simplified the procedure, should be made more widely available and promoted. Li addition, research is needed to provide a wider array of male contraceptive options.

Because women bear the major consequences of unplanned pregnancy, requiring men to meet their obligations might motivate them to take a more active role in preventing pregnancy. Few countries have policies requiring men to take financial responsibility for their offspring. Proposals for campaigns to promote male responsibility for family planning have generated useful public discussion. One poster featuring a doleful pregnant man asking, "Would you be more careful if it was you who got pregnant?" has been adapted for use in eight countries (Gallen, Liskin, and Kak 1986).

Eliminating Harmful Practices

In addition to educational and policy measures to promote positive health practices, governments and health agencies need to address harmful practices associated with women's subordinate status, such as discriminatory access to food and health care, genital mutilation, and gender violence. Because these practices arise from the social, economic, and cultural environment, cooperation and coordination on a wide scale are needed to change them.

By emphasizing the health aspects of harmful practices, governments can increase public awareness of their significance, prevalence, and impact Health workers can be trained to recognize and treat the resulting health conditions, while health agencies can document them, identify their causes and potential interventions for their control, and disseminate related information.

Gender discrimination. Health planners, managers, and providers can help sensitize policymakers, community leaders, and the general public about the profound impact that gender discrimination has on the health, well-being, and productivity of women. Public education programs on these topics can be provided as part of the essential services for women. Such programs should stress the high human costs of neglect and mistreatment of girls and women-including the long-term implications of inferior care for girls and the deleterious effects of poor nutrition and early childbearing.

While increasing public awareness is a necessary first step, the ultimate goal is the adoption of positive social norms and health behavior. Governments, therefore, will need to actively support interventions designed to change behaviors, first on a limited scale and later on the national level. Policies, cultural practices, and social norms that perpetuate women's low status need to be reexamined. Higher levels of education and vocational training for women, greater participation in the labor force, and improved access to income, land, and credit will also raise women's status and influence gender power relations.

Genital mutilation. Governments and nongovernmental organizations (NGOs), including professional organizations and women's groups, should receive encouragement and material support to work for the elimination of genital mutilation. Laws and clear policy declarations prohibiting female genital mutilation may help, but more broadly based efforts are also needed. Widespread public education programs can publicize the harmful effects of genital mutilation and address its cultural roots. Local research may be needed to determine its prevalence, the cultural reasons for its perpetuation, and its consequences, as well as to test effective approaches for preventing it (Box 3.2). Health workers can help disseminate this information to the community.

Domestic violence and rape. Violence against women is not just a health problem but a broad social problem, intertwined with gender power relations, sexuality, self-identity, and social institutions. It is therefore important not only to treat the physical and psychological injuries that result from violence, but also to examine the root causes and address the cultural and social legitimization of bodily harm and male control over female behavior.

In most countries, laws fail to protect the victims of domestic violence or to punish its perpetrators. Many violent crimes go unreported because the victim is afraid of the perpetrator and of society's skepticism, its condemnation of victims, and ostracism. Where violence against women is condoned or punished lightly, laws should be strengthened to serve as a deterrent. Key legal changes include removing barriers to prosecution (such as requirements for witnesses and evidence of permanent injury), eliminating practices that are prejudicial to women (for example, disregard of complaints by women who are not virgins and the exoneration of rapists who agree to marry their victims), and ensuring that married women have access to family assets and are free to leave abusive relationships.

BOX 3.2 ELIMINATING FEMALE GENITAL
MUTILATION

Every year 2 million girls are subjected
to genital mutilation. Unlike male circumcision,
in which the foreskin is
removed without damage to male organs,
female circumcision involves
the cutting and removal of parts or all
of the external female genitals. Practiced
mainly in Eastern and Western
Africa, it is also found in parts of Asia
and the Middle East (such as Egypt,
India, and Yemen). Prevalence is
highest in Somalia and Djibouti, where
98 percent of women are subject to
genital mutilation, 80 percent or more
of them in its most extreme form
(Toubia 1993).

Genital mutilation has serious and
sometimes fatal physical consequences,
as well as psychological effects.
The immediate consequences
can include excruciating pain, hemorrhage,
tetanus, and sepsis. The
long-term consequences may include
scarring, urinary tract infections,
painful intercourse, obstetric fistulae,
difficulty during urination and menstruation,
and complications in childbirth.

Female genital mutilation has been
discussed as both a human rights and
a health issue. In 1990 the Convention
of the Rights of the Child condemned
female circumcision as torture
and sexual abuse. The Forty-sixth
World Health Assembly in 1992
adopted a resolution calling for the
elimination of female genital mutilation
and other harmful traditional practices.
Organizations such as the Inter
African Committee on Traditional
Practices Affecting the Health of
Women and Children are working to
focus attention on and eliminate female
genital mutilation.

Because multiple cultural and social
factors contribute to the continuation
of this practice, it is best handled
nationally, with the involvement of local
women's and professional groups.
In Burkina Faso a national committee
to eradicate female genital mutilation
was established in 1990 by presidential
decree. The committee has established
provincial groups, held
workshops, and developed a film and
teaching materials (IAC 1993).

In Kenya a study conducted by a
women's organization, Maendeleoya
Wanawake Organization (MYWO),
found that approximately 90 percent
of the women interviewed had undergone
genital mutilation. Even though
most circumcised women reported
having experienced problems, more
than 65 percent expected to have their
daughters circumcised. Additional
qualitative research provided some
explanations for this practice and belief.
Circumcision signifies a rite of
passage, conferring maturity and respectability.
A girl who is uncircumcised
is considered unfit to become a
wife and mother. Benefits such as
education, gifts, celebrations, and
privileges are bestowed on the circumcised
girl, MYWO has developed a
communication program to reeducate
community leaders, parents, elders,
and youth, and it is exploring ways of
eliminating the practice (Matovina
1992; Toubia 1993; who 1993b).

Health and family planning workers can be an important source of support and referral for victims of violence. They can, however, also exacerbate the situation through insensitive and judgmental behavior. Experience has shown that most women will discuss abuse if questioned by a sympathetic health care provider. Increasingly, specialized counseling, legal, and support services are available to assist abused women who are referred from health care settings. Even where no special services are available, health care providers can be trained to emphasize that no one deserves to be beaten or to be blamed for being raped.

In many countries, NGOs are raising awareness about violence against women. In Honduras, Jamaica, and Nicaragua, for example, NGOs have used theatrical productions to generate public discussion on this topic (Heise, Pitanguy, and Germain 1994; Popular Education Research Group 1992).

Expanded Health Interventions

For developing countries with the financial resources and political will to go beyond the essential services, the expanded services provide a more comprehensive set of interventions and therefore more adequate health services for women (Table 3.2). For low-income countries that initially adopt only the essential services, the expanded services can be incorporated incrementally.

Expansion of Essential Services

Increased choice of contraceptive methods. As family planning programs expand to cover more clients through a larger network of outlets, including intensified outreach to adolescents, so the range of contraceptive methods offered should expand. Each method added attracts new users and creates more choices for current users, increasing overall contraceptive prevalence and continuation rates and more successfully meeting women's differing needs. Analysis of data from seventy-two developing countries found that access to a range of methods strongly improved contraceptive prevalence (Freedman and Berelson 1976).

In settings with sufficient infrastructure, postcoital contraception can be used to help prevent unwanted pregnancy and reduce the need for abortion. The major postcoital methods are combination pills and IUDs, which have failure rates of under 2 percent if administered within three and five days of unprotected intercourse, respectively (Van Look 1990). A relatively new drug called RU-486, which can be used within the first sixty-three days of pregnancy in combination with a dose of prostaglandin, shows promise as a nonsurgical method of early abortion. The current regimen requires medical supervision,

although alternatives are being studied. More information on the cost of RU486 and on its infrastructurai and medical backup requirements is needed before its widespread use can be advocated in low-income countries (Sundstrom 1993).

Enhanced maternity care. As the health infrastructure improves, maternity care services should be upgraded to include expanded routine and referral care, with increased coverage and full-service obstetric facilities. More detailed information on expanding maternity care services can be found in Making Motherhood Safe (Tinker and Koblinsky 1993).

With respect to prenatal care, increased attention needs to be given to the quality of care. Special efforts should be made to reach marginalized groups, such as adolescents. To improve the quality of care, maternal death audits should be introduced, and efforts should be intensified to coordinate supervision and backup from the hospital to the community level. Services will need to be decentralized, and women will need to be redirected to health centers for routine care, because referral sites will tend to become overwhelmed by demand. Birthing centers located near hospitals may provide a low-cost alternative for routine deliveries, as has been found in Mexico. As deliveries become increasingly institutionalized, providers need to resist the overuse or abuse of medical technologies such as cesarean sections (see Box 3.3) and to emphasize client-oriented care.

Expanded screening for and treatment of STDs. Health agencies can increase coverage for the screening and treatment of STDs as resources permit Key interventions include the following:

* Expanded screening and treatment of high-frequency transmitters. Intensified efforts should be made to reach high-risk groups, which include, in addition to commercial sex workers, the men who hire them, track drivers, and migrant laborers. Projects in Peru, Tanzania, Thailand, and Zimbabwe have successfully persuaded prostitutes and their clients to use condoms more regularly. Thailand's program of 100 percent condom use in brothels now covers sixty-six of the country's seventy-three provinces (Rojanapithayakorn 1992).

* Diagnosis and treatment for a broader range of RTIS. Efforts should be expanded to all women of reproductive age and should cover a broader range of RTIS, particularly pelvic inflammatory disease and some genital ulcers. Although treating patients with symptoms can help to avert serious complications and the further spread of STDs, the majority of women with STDs are asymptomatic. Furthermore, diagnosis of syndromes, such as abnormal vaginal discharge, requires the use of algorithms and/or simple diagnostic tests. Therefore, in settings where diagnostic facilities exist, specific diagnosis and appropriate treatment should be made available to women with symptoms suggestive of STDs and to asymptomatic women, especially those considered at risk, who attend prenatal, family planning, or primary health care facilities.

* Partner notification. By placing increased emphasis on notifying the partner of a person diagnosed with an std, health workers can reduce the spread of such diseases, including HIV/AIDS, and prevent reinfection after treatment Because men more frequently have symptoms, they may be more likely than women to seek care. Partner notification can lead to earlier treatment for women, thereby reducing the rate of serious complications.

BOX 3.3 INAPPROPRIATE PRACTICES
IN WOMEN'S HEALTH CARE

When misapplied, some health care
practices can jeopardize the health of
the women they are intended to benefit,
as well as squander valuable
health sector resources.

Misplaced emphasis in prenatal
care. Appropriate prenatal care with
backup for managing obstetric complications
is essential for maternal and
child health. Many countries, however,
emphasize the number of prenatal visits,
rather than the quality of care provided.
Encouraging frequent visits
strains the resources of both the patient
(who incurs travel and time costs)
and the health system. Prenatal care
is often overly dominated by an ineffective
effort to predict pregnancy
complications, most of which are unpredictable.

In the former Soviet republics,
women are seen at least twelve times
(and often more than twenty) during
pregnancy, and prenatal visits are
marked by numerous diagnostic and
lab tests, including routine ultrasonography.
Little counseling and
education regarding nutrition and family
planning is provided (Weinstein,
Oliveras, and Macintosh 1993). When
properly conducted, good-quality prenatal
care can be provided through as
few as three to six prenatal visits.

Unwarranted cesarean sections.
Under appropriate conditions, cesarean
section can be a life saving procedure
for the mother and infant. However,
the incidence of cesarean sections
is not always justified on medical
grounds. In Brazil, for example,
the cesarean rate exceeds 30 percent
(PAHO 1993). By contrast, cesarean
rates range from 5 to 20 percent in
industrial countries (Chalmers, Enkin,
and Kierse 1989.) Misuse of cesarean
sections not only adds to health
care costs (raising costs by $13.4 million
in Brazil in 1985) but also exposes
women to far greater health risks than
they face during vaginal deliveries.
Studies in Latin America indicate that
the decision to perform cesarean sections
is based not only on maternal or
fetal need but also on economic considerations
of health care providers
and hospitals (PAHO 1993) and the
convenience of both the provider and
patient.

Misdirected screening for cervical
cancer. The limited cervical cancer
screening conducted in developing
countries is generally provided
through family planning and maternal
and child health clinics. Such an approach
erroneously targets younger
women rather than those aged 35
years or older, who are most at risk in
most regions. Screening women from
age 35 has been shown to be at least
90 percent as effective as screening
from age 25 and to cut costs by one-third
(Miller 1992).

* Reducing the transmission of HIV through blood transfusions. Pregnant women, in particular, have an increased exposure to blood transfusions. Educating health care providers about possible risks and establishing guidelines can reduce the number of transfusions by more than 50 percent at negligible expense (World Bank 1993b). Where blood banks exist donated blood can be screened for an additional cost of about 5 percent. Where such facilities are not available, rapid tests (such as the dipstick) are needed.

* HIV counseling and testing. Where HIV prevalence is high, women of reproductive age should receive counseling and have the option of being tested for the virus. HIV-infected pregnant women should be counseled about the risk that their child may be HIV-infected, and they should be informed of their options. These may include abortion and, where affordable, therapy with AZT, a drug that may reduce risk of transmission to newborns by as much as two-thirds (CDC 1994).

Nutrition assistance for vulnerable groups. The essential services focus on nutrition assistance for pregnant women. Expanded services should extend this assistance to other groups at risk of malnutrition, including young girls, adolescent girls, and elderly women. Special programs for refugees and dislocated persons may also be needed.

Nutrition strategies fall into two major categories: (a) decreasing energy loss by controlling fertility, preventing infections, and reducing the physical workload, and (b) increasing intake by improving the diet, reducing inhibitors that limit the efficiency of food absorption, and providing food and micronutrient supplements. Nutrition programs should assess the nutritional status of girls and women at risk and provide food supplements as needed, improve nutritional habits through counseling and public education, and identify appropriate local food sources. In collaboration with other agencies, nutrition programs should promote healthier fertility patterns and greater use of labor-saving technologies (Ghassemi 1990).

Governments can promote better nutrition by ensuring that low-income families have the means to purchase nutritious foods. Measures to ensure adequate food supplies include consumer price supports for staple foods, income transfers for vulnerable households, and food fortification.

Three major types of nutrition interventions can be used to improve the nutritional status of women and girls.

* Food supplementation. If properly targeted and tailored to local market conditions, food supplementation programs can have a substantial impact on nutritional status (World Bank 1993b). In Guatemala, for instance, pregnant women who received food supplements had babies with higher birthweights than women who received no supplements (Villar and Rivera 1988). Although food supplementation programs are costly to implement and maintain, they may be the only effective means of improving the nutritional status of extremely poor populations.

* Micronutrient supplementation. Appropriate micronutrient supplementation throughout the life cycle--such as iron and folate pills, vitamin A capsules, and iodized oil--can be highly effective in overcoming related deficiencies (World Bank 1993b). Most micronutrient programs cost less than $50 per DALY gained (for more details, see World Bank forthcoming).

* Food fortification. Adding micronutrients (such as iron, vitamin A, and iodine) to processed foods can be a simpler and quicker means of improving nutritional status than changing diets. To be effective, fortified foods must be readily available, widely consumed by the target population, and relatively inexpensive (World Bank 1993b). Food fortification is a cost-effective option where adequate infrastructure is in place.

Screening, treatment, and referral for victims of violence. Health care providers can play a key role in identifying survivors of violence and referring them to appropriate social and legal services. Only a few simple questions are needed to screen for physical or sexual abuse. Screening programs can be introduced in prenatal clinics, emergency rooms, and other health facilities to assess women's risk of exposure to violence. Health facility protocols designed to identify victims of violence can help ensure timely intervention and gather information on the severity of the problem. Health care providers and other professionals who deal with women need to be trained to recognize signs of abuse, record information on the incidence and consequences of violence, provide sensitive counseling and treatment, collect legal evidence for the prosecution, and refer victims to appropriate services.

At least forty developing countries have NGOs that assist survivors of violence through rape crisis centers, centers for battered women, legal aid, and other services. A few governments, including those of Brazil, Mexico, and Papua New Guinea, also provide services to battered women and rape victims. Malaysia has formed women-only teams at police stations and hospitals. In Costa Rica one NGO trains teachers, therapists, and social workers to run support groups for victims of sexual abuse (Heise, Pitanguy, and Germain 1994).

Specific violence-related services that health agencies should offer are:

* Postcoital contraception for rape victims. Offering postcoital pills, IUD insertion, or abortion to rape victims can spare them the additional trauma of unwanted pregnancy.

* Screening and referral. Health care workers can perform an important service simply by breaching the wall of silence that surrounds abuse and putting women in contact with services designed to deal with violence-related problems. Screening should be conducted privately and be as noninvasive as possible, as part of a more general process of questioning about the woman's sexual and gynecological history. Clinic staff should contact local women's groups to familiarize themselves with support services. Often, advocacy groups and crisis centers have information materials that can be displayed in waiting areas.

* Record keeping. To interrupt the cycle of violence, health care providers need to take special care to collect evidence of violence in a form that is adequate for legal action. Such information can also be used to document the extent of violence.

Cancer Screening and Treatment

Early detection of cancer is important because treatment is most effective in the early stages of the disease. The cost-effectiveness of cancer-screening programs depends on the incidence of the disease, the technical feasibility of screening and treatment at early stages, and the possibility of targeting high-risk groups.

Cervical cancer. Screening for cervical cancer is particularly cost-effective because the disease can be treated relatively easily in its early stages. The most common screening method is the Pap smear, but other, more economical, methods (such as visual examination, either unaided or aided by low-power magnification, and acetic acid treatment of the cervix) are now being evaluated for clinical use. Treatment of preinvasive cervical lesions is very successful and can be conducted cost-effectively using cryotherapy and loop excision. Treatment for more advanced stages requires surgery and sometimes radiation, which are far less effective and more expensive (Miller 1992).

Studies have shown that screening all women once in their lifetime prevents many more cases of cervical cancer than screening a small proportion of women every few years. The goal should be to screen every woman 35 to 40 years of age at least once. If more resources are available, the frequency of screening could be increased to every ten years for women aged 35 to 55. If a high proportion of the target group is being screened, and resources permit, screening should be extended first to older women up to age 60 and then to younger women down to age 25 (Miller 1992; see also Box 3.3). In parts of Africa, cervical cancer appears to occur earlier than in other countries, and thus targeting women younger than 35 before targeting those over 55 may be more cost-effective.

A program that screens all women over age 35 for cervical cancer at fiveyear intervals costs an average of $100 per DALY gained. Increasing the screening interval reduces the cost (Jamison 1993). In countries where resources are more limited, feasible and cost-effective screening programs should treat only severe dysplasia or carcinoma in situ and should use such relatively inexpensive outpatient treatments as cryotherapy and loop excision (Sherris and others 1993).

Breast cancer. Early detection is equally important for breast cancer. The most cost-effective method of breast cancer screening is physical examination (both by the woman herself and by health care providers). Physical examination alone can detect about two-thirds of the cancers detected by mammography. Where additional resources are available and breast cancer is common, mammography can be used as a diagnostic tool, although this increases the cost tenfold when done on an annual basis. Screening programs that include periodic examination by a trained health worker and a mammogram once a year for women aged 50 to 69 can reduce breast cancer mortality by 30 to 40 percent when appropriate treatment is provided (Miller and others 1990). Treatment of breast cancer, however, requires relatively expensive surgery, radiation therapy, and chemotherapy and is not likely to be cost-effective in many developing-country settings.

The inclusion of breast cancer management in the expanded services will depend on local prevalence and resource availability. In countries where the incidence of breast cancer is on the rise (because of declining fertility, dietary influences, and environmental carcinogens) and where adequate resources are available, breast cancer screening and treatment may form a component of the expanded services.

Expanded Interventions for Behavioral Change

Most health services have paid little attention to the special health needs of school-age girls and adolescents, which differ from those of young children and adults. Adolescence, in particular, is a period of rapid change and growth. Overall health status during these years carries over into adulthood. It is also the time when unhealthy behaviors may begin.

Health services could realize substantial benefits by intensifying programs for school-age girls and especially adolescents. Programs need to appeal to these young women directly by focusing on their needs and preferences. In general, reaching them through existing institutions, such as schools, is more cost-effective than motivating them to come to a new site. Since peer education programs have been more effective than adult-directed initiatives, youths should be involved in program planning and implementation.

Health Education for Early Prevention of Health Problems

Working through education systems, governments can provide information to girls and adolescents on general health and disease prevention, contraception, STDs, HIV/AIDS, substance abuse, and nutritional needs. School curricula can also cover communication skills, strategies for resisting peer pressure, and negotiating techniques. A curriculum on "Life Planning" that emphasizes experiential, interactive learning and puts sexuality in a broader life context has proved successful in increasing knowledge and changing attitudes (WHO 1992a). Governments can also support nonformal education programs, including peer education and community outreach, in order to reach adolescents where they live, learn, work, and play.

With the aids pandemic making early sexual experimentation potentially life-threatening, it is particularly vital that preteen and adolescent girls understand the basic facts about sexuality and reproductive health so that they can make responsible decisions about their sexual behavior. Sex education and contraceptive services must be made available in all cultural settings, regardless of age or marital status. Restricting adolescents' access to contraceptive information and services has not reduced premarital sexual activity, but it has left adolescents without the means to make responsible choices and protect themselves from unintended pregnancy, STDs, and HIV.

Young people and their caregivers are often unaware of the increased need for energy-producing foods and micronutrients during adolescence to support physical development and prepare young women for childbearing. Nutrition education, provided through multiservice and vocational training centers, has been effective in improving adolescents' nutritional status (who 1986).

In all countries adolescence is a period when important lifestyle patterns are established, making it an important time to influence decisions about the use of tobacco, alcohol, and drugs. Since smoking is increasing fastest among young women, public education programs, school curricula, and advertising regulations can place special emphasis on persuading young women not to smoke. Mass media campaigns can counter advertising directed to young women that portrays smoking as glamorous and sophisticated behavior. Governments can also restrict the advertising and sale of tobacco products to minors, tax such products, and regulate tobacco production and imports. Messages need to stress the hazards and disadvantages of smoking and to promote alternative strategies for coping with stress.

Increased Efforts to Reduce Gender Discrimination and Violence

Instead of merely treating injuries, malnutrition, and other health problems that derive from society's general neglect of women, governments can move vigorously to address gender discrimination and violence. Countries that can afford to go beyond the essential services should define clear strategies for reducing discriminatory attitudes and practices and gender-related violence. Health agencies should concentrate on three major areas:

* Public education initiatives. Much can be accomplished by bringing attention to the social practices that favor males and perpetuate violence against women and by emphasizing the harmful effects of such practices on women's health. Public education initiatives can influence the content of popular radio and television programs, educate media representatives, and promote news coverage of gender discrimination and violence.

* Health care training. Regular pre- and in-service training for health care providers is needed to sensitize staff to practices that are harmful to women and to teach the skills needed to address these practices. Health care providers need to be aware of possible barriers to communication with female clients and of ways to elicit women's judgments about their own health needs and to meet these needs effectively.

* Community participation. Although health care providers can deal with only a fraction of the problems associated with discrimination and violence against women, they can put women in touch with other support agencies. To do this, they need to establish ties with law, education, employment, credit, and community resources and to support networks of professionals and community activists.

Women beyond Reproductive Age

To improve the health and productivity of women aged 45 and older, as well as the associated costs of curative care, more attention needs to be given to preventing problems--through proper diet and exercise; avoidance of tobacco, excessive alcohol, and other harmful substances; screening for cervical cancer and other chronic diseases to the extent that resources permit; and health education to promote self-help.

Health care providers should advise women of all ages of the importance of an adequate diet. Osteoporosis, for instance, which accelerates after menopause, is best prevented through early intake of sufficient levels of calcium. To reduce the risk of bone fracture after menopause, women should be encouraged to improve their diet, exercise regularly, stop smoking, and reduce their consumption of alcohol. Although estrogen therapy is known to retard bone loss, it is not yet a cost-effective public health measure for developing countries (Lindsay 1993).

As women approach menopause (generally between ages 45 and 55), they need counseling about the physical and mental symptoms that may develop as their estrogen levels decline. For most women these symptoms are relatively mild and subside within two years. In counseling menopausal women and helping them to cope with hormonal changes, health care providers should be instructed to be reassuring and compassionate.

With increasing widowhood and divorce, and changing household composition, an increasing number of households are headed by women who may need assistance to meet their domestic, childrearing, and economic responsibilities. Many older women now live alone, which contributes to their isolation and can make it difficult for them to eat properly and maintain their health. In some places widows are subject to active discrimination, exacerbated by inheritance laws and customs that fail to protect their rights.

Sustainable solutions will need to rely on efforts to integrate older women into the community and increase their capacity for self-help. Health care providers can relieve the isolation of elderly women and improve their medical and social condition by linking them with support networks such as day centers for the elderly, peer groups, and agencies that provide food and housing. For example, the Center of the Aged in India promotes community-based services such as drop-in facilities for seniors, often run by the elderly themselves (Tout 1989).

TABLE 3.1 ESSENTIAL SERVICES FOR WOMEN'S HEALTH

                                   Essential interventions
Essential health interventions     for behavioral change

PREVENTION AND MANAGEMENT          PROMOTION OF POSITIVE
OF UNWANTED PREGNANCIES            HEALTH PRACTICES

* Family planning                  * Laws, education, and services to
* Management of complications        encourage delayed childbearing
  from unsafe abortion               among adolescents
* Termination of pregnancy         * Counseling and public education
                                     to promote safe sex
PREGNANCY SERVICES                 * Public education and programs to
                                     ensure adequate nutrition
Prenatal care                      * Strategic efforts to increase
* Prompt detection, management.      male involvement in women's
  and referral of pregnancy          health issues
  complications
* Tetanus toxoid immunization      ELIMINATION OF HARMFUL PRACTICES
* Iron and folate supplements
* Iodine supplements, where        * Public education and services to
  warranted                          discourage gender discrimination.
* Malaria prophylaxis in             domestic violence, and rape
  infested areas                   * Policy dialogue and public
                                     education to discourage female
Safe delivery                        genital mutilation
* Hygienic routine delivery
* Detection, management, and
  referral of obstetric
  complications
* Facility-based obstetric care

Postpartum care
* Monitoring for infection and
  hemorrhage

PREVENTION AND MANAGEMENT
OF SEXUALLY TRANSMITTED DISEASES

* Condom promotion and
  distribution
* Prenatal screening and
  treatment for syphilis
* Symptomatic case management
* Screening and treatment of
  commercial sex workers

TABLE 3.2 EXPANDED SERVICES FOR WOMEN'S HEALTH

                                     Additional Interventions
Additional Health Interventions      for Behavioral Change

EXPANSION AND IMPROVEMENT            INCREASED ATTENTION TO EARLY
OF ESSENTIAL SERVICES                PREVENTION OF HEALTH PROBLEMS

* Increased choice of                * In-school education about
  contraceptive methods                reproductive physiology.
* Enhanced maternity care              sexuality, and reproductive
* Expanded screening for and           health
  treatment of sexually              * Public information and
  transmitted diseases                 services to prevent unwanted
* Extended nutrition assistance        pregnancy and sexually
  to vulnerable groups                 transmitted diseases
* Screening, treatment, and          * Education about girls* special
  referral for victims of violence     nutritional needs
                                     * Education to discourage smoking
CANCER SCREENING AND TREATMENT         and substance abuse

* For cervical cancer from age 35    STRATEGIC EFFORTS TO REDUCE
* For breast cancer from age 50      GENDER DISCRIMINATION AND VIOLENCE
  (where resources permit)
                                     * Public education initiatives
                                     * Training for health care workers
                                     * Networking within the community

                                     GREATER FOCUS ON WOMEN BEYOND
                                     REPRODUCTIVE AGE

                                     * Education about nutritional
                                       requirements
                                     * Self-help links with support
                                       networks